FILE NO. 121

INTERVIEW WITH DR. PAVEL HAAS, CHIEF OF SURGERY

Location: Hospital for Special Surgery (HSS), New York, NY

—How is Mr. Couture doing?

—His femur, tibia, and fibula are broken in several places on both legs. He has no patella to speak of, on either leg. His knees have just been obliterated. There’s nothing but small fragments piercing through his flesh like shrapnel. To put it mildly, his legs are gone.

—He is under the impression that you will cut them away.

—He’s right. They’re prepping the OR as we speak. We’ll take him upstairs as soon as we’re done here. We’ll cut his legs about midway to the knee. There should be enough left to attach prosthetics if we’re lucky. It will take some time, but most patients in his situation eventually learn to walk again. I know it sounds terrible right now, but you have to believe me when I tell you, this is what’s best for him.

—That is more or less what he told me. I am sorry to tell you that an amputation is out of the question.

—I don’t want to be rude, but this really isn’t up to you.

—How I wish that were true. Unfortunately, there are a great many things that fall under my responsibility and this happens to be one of them.

I can see your mouth opening slightly, which would suggest that you are waiting for the first opportunity to interrupt me, so I will save you the time and give you the only justification you are going to get.

That man is in a unique position to do something remarkably important for this country, if not for mankind. More to the point, he is the only one who can, and he needs his legs to do it. I apologize if this is more succinct than what you were hoping for, but it will have to do under the circumstances.

—You can’t…

—Please do not interrupt. I understand you are in a position of authority and the nature of your work probably makes you unaccustomed to being contradicted. But if what I have been told is true, we do not have a lot of time before sepsis sets in, so I hope you will forgive me for being blunt.

If you insist on pursuing this course of action, these two men will escort you out of the building and drive you away. I do not want you to think I am threatening you. You will not be killed, and no one will inflict physical pain upon you. You will, however, wake up in a strange room and never see the outside of it for the remainder of your life.

I just want you to have all the facts so you can make an informed decision. Unfortunately, you will need to make that decision in the next thirty seconds.

—I don’t know how I’m supposed to answer that.

—You do not have to answer. You just have to do exactly as I say. I was told you are the best at what you do. That is why we flew him here. That is why we chose you. It will take me about ten minutes to get someone almost as good to replace you, but I really hate having to settle for second best.

—You don’t understand. I can’t salvage any of the bones—not me, not anyone else. It’s not a matter of will, and threatening me won’t change anything. I can’t “wish” his bones back together. And I can’t just make him new legs out of thin air.

—Sure you can. You wrote several papers on titanium implants and you have the highest success rate in titanium total hip replacements. You may or may not lack some of the mechanical engineering skills to create implants of this size, but we can remedy the situation with one phone call. I believe you already have all the equipment you need, but if you require anything else, I will have it flown here within the hour.

You will enjoy unlimited funding, and you may use any and all of the resources of the United States Army, the NIH, the NSF, NASA, as well as those of agencies you have never heard of. If you require anything, simply call this number and mention your name. Someone will make sure that you get all that you need. It is vital that you realize the colossal amount of resources at your disposal. I would not want this experiment to fail because you assumed certain technologies did not exist, or that certain materials were unobtainable. Right now, at this very moment, you are the most powerful person in the medical field on the planet.

—We’d have to replace every single bone in his legs. Basically, we’d be inserting whole mechanical legs inside his tissue. It’s never been done, there’s a reason for that. The human body is hostile to foreign objects. I’m not even sure we could salvage enough muscle for them to be functional, but his body would absolutely reject such a large implant. I can guarantee it. We’ll just end up killing him.

—That is precisely what I was talking about. You need to understand how much you do not know, and you need to understand it very quickly. In about twenty minutes, you will receive a call from someone at the US Army Medical Research and Materiel Command. They will provide you with a new immunosuppressive agent they have been working on. That should help him accept his new legs. They will also send a muscle-building agent that…

—I can’t inject a patient with something I know nothing about.

—It is a myostatin inhibitor, much more efficient than anything else you may have read about. I am confident it will come with some sort of label. They tell me it works wonders on mice. Do not waste precious time pretending. We both know you are as curious as I am to see it work. You will get to use experimental drugs the FDA will not even hear about for another decade.

—You obviously don’t care about my opinion, but I want to make sure you understand. He could live a very productive life with prosthetics if we amputate now.

—He will live an astoundingly productive life after you build him new legs.

—I need to think about this.

—You do not. You made up your mind about twenty seconds ago. You see, Dr. Haas, our jobs are not that different. We analyze the situation, we gather as much data as we can before we take action, and we try to anticipate every possible outcome. I did my job as thoroughly as I hope you will do yours. You gained a tremendous amount of the knowledge we are now asking you to use during two extensive studies funded with corporate money, one on tapered titanium cementless total hip replacement, and the other on tissue response in failed titanium implants. In 2006, two of the patients participating in your hip replacement study rejected their implants, one of them died of complications. Interestingly, there is absolutely no trace of these two patients in any of your grant proposals, or in any of your publications. Somehow, however, their data show up in a tissue-response study they never took part in. You switched the patients from one study to the next, as if nothing ever happened. No harm, no foul, except for a dead patient.

—That woman had a heart condition she didn’t tell me about. I would never have chosen her for this study had she not lied in her application.

—I have no doubt. Putting her in your report would not have saved her. You just made the preliminary results look this much better to the people paying for it.

More to the point, when you immigrated to this country, you also neglected to declare that you were arrested for driving under the influence. I realize it is only a misdemeanor in the United States, but it is a criminal offence where you come from.

You are egotistic enough to believe that the rules do not really apply to you, that these little white lies served a greater good, and that you were actually helping others. It is not uncommon with people of your background.

—My background?

—Raised in precarious conditions by a poor family with traditional values. First one in the family to get a college education. First to rise out of poverty. It sounds cliché, I know, but we have become very proficient at this sort of profiling. One thing is certain: you are a survivor, Dr. Haas. You are definitely not one to throw away your life, your family, and your career for something as petty as principles.

When you leave this room, you will make sure that enough of the remaining living tissue in Mr. Couture’s legs is preserved while you construct his new bones.

—If we do this, and by some miracle it works, I can guarantee he’ll wish he had died on the operating table. He’ll beg for us to end his life. You simply can’t imagine the amount of pain he’ll have to suffer. Every minute of every day will be the worst of his life. Will you be the one to tell him that?

—I would rather not. That is a horrible thing to tell anyone, especially before life-threatening reconstructive surgery. Will he suffer any less if we tell him that he will?

—No. He’ll go through hell no matter what; if he doesn’t die first.

—Then I see no reason to tell. I want him in as good a mental state as humanly possible. I want you to tell him everything will be fine.

—I want the record to show that this procedure is being done against medical advice and that I am participating under duress.

—I am recording this conversation so anything we have said so far is on the recording. You may call this a record, if you wish. If you were referring to the hospital records, then no. This is your idea and yours alone. You are performing this surgery because you firmly believe this is the best solution for your patient and you have every confidence in its success. There will be no reference to this conversation, in any form, whatsoever. Let me be abundantly clear on this. Any mention of my presence, of my very existence, to anyone, will have dire consequences for both you and your loved ones.

—What kind of consequences?

—I have not yet had time to ponder an appropriate response, but I can guarantee that you will never see your children again, even if the operation is successful.

—What if it isn’t?

—Then you will almost certainly lose your medical license.

—No. I won’t say anything. But what if the patient doesn’t survive? What are you threatening me with?

—Why would I threaten you if you do exactly as I ask? I am not evil, Dr. Haas. That said, you will most likely lose your medical license, along with your house, your car, and everything you own. I would expect some jail time. You are about to perform absurdly complex, insanely risky, and completely unnecessary experimental surgery on a stable patient without his knowledge or consent. What do you think will happen if he dies?

Before you go, I also want you to take a look at these designs. You will need to integrate them into your leg structure.

—What are they?

—Knees.

—I’m not a mechanical engineer, but it looks like they…

—Yes, Dr. Haas. They do.